Orthodontic Insurance Information Form
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Complete Orthodontic Insurance Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1Damon W . DeArment, DDS
Daniel J. Lill, DDS MS
ORTHODONTIC INSURANCE INFORMATION
In order to assist you in determining your orthodontic insurance benefit, the following information is necessary:
Name of Patient:
Date of Birth:
Name of Insured:
Date of Birth:
Address:
Social Security #:
Telephone:
Employed by:
Insurance Company:
Policy #:
Insurance Telephone:
Group #:
Is patient covered under another dental plan? If so, please complete the following:
Name of Insured:
Date of Birth:
Address:
Social Security #:
Telephone:
Employed by:
Insurance Company:
Policy #:
Insurance Telephone:
Group #:
I hereby authorize release of any information relating to this claim.
Signature:
Date:
I hereby authorize payment of insurance benefits directly to the above named orthodontist.
Signature:
Date:
~PLEASE REMEMBER TO CALL US WITH ANY INSURANCE CHANGES DURING TREATMENT~
Save this form on your computer before filling out. Once completed, you can either print the document and bring with you
to your next appointment or save the filled out form and email to
Winchester
Front Royal
1010 Amherst Street
920 N. Shenandoah Ave.
Winchester, VA 22601
Front Royal, VA 22630
540-667-9662
540-635-1695
540-722-0597 fax
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